Job Requirements
Position Summary
The Senior Coder, under the direction of the Coding Manager, is responsible for the coding and abstracting of a variety of patient types. (IP, OBV, OPS, ER, IR, Endo etc.). The senior coder may also be responsible for the charging of certain revenue codes on designated patient types. The Senior Coder works with providers to ensure documentation is clear and concise to support the coding and charging. Compliant queries are written to providers if needed which become part of the legal medical record.
Minimum Requirements
Education
- High School Diploma or Equivalent
- Coding Certification Program (AHIMA or AAPC) or courses in coding, medical terminology, and anatomy/physiology.
Experience
- ICD-10-CM/PCS and CPT coding experience- 2 years OR will train recent graduates from an AHIMA certified HIM program with a BS or associate degree.
License/Registration/Certifications
Preferred Requirements
Preferred Education
- Associates or bachelor?s degree in HIM or related Health care field
Preferred Experience
- 2-3 years of hospital-based coding experience
- Experience with the use of an encoder and EMR
Preferred License/Registration/Certifications
- At least one active certification (RHIA/ RHIT/CCS) or other credential in heath related field
Core Job Responsibilities
- Reviews facility inpatient and outpatient medical documentation to accurately assign ICD-10-CM/PCS and MSDRG in accordance with coding policies and guidelines. Assigns facility charge code for Emergency Center encounters.
- Verifies assignment of MSDRG, MCC/CCs, Hospital Acquired Conditions (HACs) and Patient Safety Indicators (PSIs) based on documentation.
- Assign Present on Admission (POA) indicators to each diagnosis code to distinguish between conditions that were present when patient was admitted and those that developed during the hospital stay.
- Identifies unclear or ambiguous medical documentation not addressed concurrently that requires a physician query. Submits queries following AHIMA guidelines and SRHS policies.
- Abstracts key data required from the medical information consistent with UHDDS requirements in Epic and Encoder software.
- Adheres to productivity and accuracy standards.
- Researches and stays current with healthcare coding guidelines.
- Works as a team with physicians, CDI Specialists, coding team and other hospital personnel to ensure proper and accurate code assignment and continuous quality improvement.
- Actively participates in education sessions to maintain and improve coding skills.
- Other duties as assigned.
Read Full Description